In North Carolina, we take seriously the recommendation from the Institute of Medicine (IOM) to prepare nurses for leadership. This is a daunting task, if you understand the history of nursing. Traditionally, women in our society have been groomed to be unassertive and (usually male) others were looked to for ideas and directions. This was no less true, and perhaps even more true, in the field of nursing. However, for modern health care systems to address patients’ needs efficiently and well, today’s nurses must speak up to provide their insights and help lead a necessary transformation in health care.

Encouraging leadership has been chosen as a key recommendation of the IOM’s recent report—The Future of Nursing: Leading Change, Advancing Health—and one that is most likely to result in positive change in health care in the coming years. The North Carolina Action Coalition is focusing on three aspects of leadership support: preparing nurses for participation on boards of directors; mentoring nurse leaders; and defining the competencies of nurse leaders. The Coalition has assembled three task forces to address each of these issues.

As chair of the task force charged with preparing nurses to serve on boards of directors, I have worked with my colleagues to target hospitals to increase the percentage of nurses in positions of influence. Currently, fewer than 20 percent of hospitals in North Carolina have a nurse on the hospital board. Yet, the kind of practical, on-the-floor knowledge about safety and quality that nurses can provide is essential for hospitals to fulfill their mission to provide the best patient care in the most economical way possible.

The need for this kind of input is reinforced by the fact that Medicare and Medicaid do not reimburse for adverse events. It is the responsibility of the board to require safety and quality care, yet without nurses’ knowledge, board members may not have the information necessary to understand the issue or the solution. The chief nursing executive’s report to a board and her attendance at a board meeting is not a decision-making role that comes with full board participation, nor does it ensure that the board understands the information that she presents to them in passing. Rather than episodic input, nurses need to be a constant presence on hospital boards, with full decision-making authority.

While boards must be prepared to include nurses, nurses themselves need to be suitably prepared to take on the role that this kind of leadership demands. Thus, at the East Carolina University College of Nursing, a new graduate-level course will be offered during the fall semester this year. The course features a heavy emphasis on reading and understanding financial reports—balance sheets, profit/loss statements, cash flow, audits and ratios. A heavy emphasis will also be placed on understanding the difference between management and governance, as well as appreciating the political aspect of relationships in organizations.

The second task force, which addresses mentoring nurse leaders, has focused its efforts on identifying mentors and those who need mentoring. They are recruiting current nurse leaders to serve as mentors, using the extensive literature on mentoring to train them in the science and the art of mentoring in order to create a positive experience for both the mentor and the mentee. They have created an online leadership institute to help emerging nurse leaders define their own abilities and then seek mentoring from senior nurse leaders. In a bold example of thinking outside the box, they have even recruited a nurse to mentor new deans, thus creating a model for introducing the concept of nurse leadership early in experiences of key stakeholders in health care systems.

The work of the third task force, devoted to defining the competencies of nurse leaders, is just beginning, but it is, quite rightly, viewed as an essential ingredient to encourage nurses to lead.

The progress that has been made by these three task forces and the promise of exciting developments to come are essential to improving nurse leadership in North Carolina. Still, there are a number of issues that are yet to be addressed. One is how to get nurses to step forward to use the knowledge they have—an issue that is found everywhere when women begin to step into more powerful positions. We continue to explore why nurses are not already leading, given their considerable and unique system and health care knowledge. Often, history shows, women who venture out into leadership must be twice as prepared as others in order to attain the same positions. We must, then, give them the skills, the confidence and the opportunities to lead.

North Carolina is at the beginning stages of this journey to improve nurse leadership. Given the need to improve health and health care delivery in our state, it is a journey we must take. But it will be well worth the effort as we see the payoff in terms of improved patient care, greater cost efficiency, and a more effective use of one of this state’s greatest health care assets: its nurses.